42 U.S. Code § 1395d - Scope of benefits

The benefits provided to an individual by the insurance program under this part shall consist of entitlement to have payment made on his behalf or, in the case of payments referred to in section
1395f(d)(2) of this title to him (subject to the provisions of this part) for—

(1)inpatient hospital services or inpatient critical access hospital services for up to 150 days during any spell of illness minus 1 day for each day of such services in excess of 90 received during any preceding spell of illness (if such individual was entitled to have payment for such services made under this part unless he specifies in accordance with regulations of the Secretary that he does not desire to have such payment made);

(2)

(A)post-hospital extended care services for up to 100 days during any spell of illness, and

(B) to the extent provided in subsection (f) of this section, extended care services that are not post-hospital extended care services;

(3)in the case of individuals not enrolled in part B of this subchapter, home health services, and in the case of individuals so enrolled, post-institutional home health services furnished during a home health spell of illness for up to 100 visits during such spell of illness;

(4)in lieu of certain other benefits, hospice care with respect to the individual during up to two periods of 90 days each and an unlimited number of subsequent periods of 60 days each with respect to which the individual makes an election under subsection (d)(1) of this section; and

(5)for individuals who are terminally ill, have not made an election under subsection (d)(1) of this section, and have not previously received services under this paragraph, services that are furnished by a physician (as defined in section
1395x(r)(1) of this title) who is either the medical director or an employee of a hospice program and that—

(A)consist of—

(i)an evaluation of the individual’s need for pain and symptom management, including the individual’s need for hospice care; and

(ii)counseling the individual with respect to hospice care and other care options; and

Payment under this part for services furnished an individual during a spell of illness may not (subject to subsection (c) of this section) be made for—

(1)inpatient hospital services furnished to him during such spell after such services have been furnished to him for 150 days during such spell minus 1 day for each day of inpatient hospital services in excess of 90 received during any preceding spell of illness (if such individual was entitled to have payment for such services made under this part unless he specifies in accordance with regulations of the Secretary that he does not desire to have such payment made);

(2)post-hospital extended care services furnished to him during such spell after such services have been furnished to him for 100 days during such spell; or

(3)inpatient psychiatric hospital services furnished to him after such services have been furnished to him for a total of 190 days during his lifetime.

Payment under this part for post-institutional home health services furnished an individual during a home health spell of illness may not be made for such services beginning after such services have been furnished for a total of 100 visits during such spell.

(c) Inpatients of psychiatric hospitals

If an individual is an inpatient of a psychiatric hospital on the first day of the first month for which he is entitled to benefits under this part, the days on which he was an inpatient of such a hospital in the 150-day period immediately before such first day shall be included in determining the number of days limit under subsection (b)(1) of this section insofar as such limit applies to

(1) inpatient psychiatric hospital services, or

(2) inpatient hospital services for an individual who is an inpatient primarily for the diagnosis or treatment of mental illness (but shall not be included in determining such number of days limit insofar as it applies to other inpatient hospital services or in determining the 190-day limit under subsection (b)(3) of this section).

(1)Payment under this part may be made for hospice care provided with respect to an individual only during two periods of 90 days each and an unlimited number of subsequent periods of 60 days each during the individual’s lifetime and only, with respect to each such period, if the individual makes an election under this paragraph to receive hospice care under this part provided by, or under arrangements made by, a particular hospice program instead of certain other benefits under this subchapter.

(2)

(A)Except as provided in subparagraphs (B) and (C) and except in such exceptional and unusual circumstances as the Secretary may provide, if an individual makes such an election for a period with respect to a particular hospice program, the individual shall be deemed to have waived all rights to have payment made under this subchapter with respect to—

(i)hospice care provided by another hospice program (other than under arrangements made by the particular hospice program) during the period, and

(ii)services furnished during the period that are determined (in accordance with guidelines of the Secretary) to be—

(I)related to the treatment of the individual’s condition with respect to which a diagnosis of terminal illness has been made or

(II)equivalent to (or duplicative of) hospice care;

except that clause (ii) shall not apply to physicians’ services furnished by the individual’s attending physician (if not an employee of the hospice program) or to services provided by (or under arrangements made by) the hospice program.

(B)After an individual makes such an election with respect to a 90-day period or a subsequent 60-day period, the individual may revoke the election during the period, in which case—

(i)the revocation shall act as a waiver of the right to have payment made under this part for any hospice care benefits for the remaining time in such period and (for purposes of subsection (a)(4) of this section and subparagraph (A)) the individual shall be deemed to have been provided such benefits during such entire period, and

(ii)the individual may at any time after the revocation execute a new election for a subsequent period, if the individual otherwise is entitled to hospice care benefits with respect to such a period.

(C)An individual may, once in each such period, change the hospice program with respect to which the election is made and such change shall not be considered a revocation of an election under subparagraph (B).

(D)For purposes of this subchapter, an individual’s election with respect to a hospice program shall no longer be considered to be in effect with respect to that hospice program after the date the individual’s revocation or change of election with respect to that election takes effect.

(e) Services taken into account

For purposes of subsections (b) and (c) of this section, inpatient hospital services, inpatient psychiatric hospital services, and post-hospital extended care services shall be taken into account only if payment is or would be, except for this section or the failure to comply with the request and certification requirements of or under section
1395f(a) of this title, made with respect to such services under this part.

(1)The Secretary shall provide for coverage, under clause (B) of subsection (a)(2) of this section, of extended care services which are not post-hospital extended care services at such time and for so long as the Secretary determines, and under such terms and conditions (described in paragraph (2)) as the Secretary finds appropriate, that the inclusion of such services will not result in any increase in the total of payments made under this subchapter and will not alter the acute care nature of the benefit described in subsection (a)(2) of this section.

(2)The Secretary may provide—

(A)for such limitations on the scope and extent of services described in subsection (a)(2)(B) of this section and on the categories of individuals who may be eligible to receive such services, and

(B)notwithstanding sections
1395f,
1395x(v), and
1395ww of this title, for such restrictions and alternatives on the amounts and methods of payment for services described in such subsection,

as may be necessary to carry out paragraph (1).

(g) “Spell of illness” defined

For definitions of “spell of illness”, and for definitions of other terms used in this part, see section
1395x of this title.

Subsec. (a)(3). Pub. L. 105–33, § 4611(a)(1), substituted “for individuals not enrolled in part B of this subchapter, home health services, and for individuals so enrolled, post-institutional home health services furnished during a home health spell of illness for up to 100 visits during such spell of illness” for “home health services”.

Subsec. (a)(4). Pub. L. 105–33, § 4443(a), substituted “and an unlimited number of subsequent periods of 60 days each” for “, a subsequent period of 30 days, and a subsequent extension period”.

1990—Subsec. (a)(4). Pub. L. 101–508, § 4006(a)(1), substituted “90 days each, a subsequent period of 30 days, and a subsequent extension period” for “90 days each and one subsequent period of 30 days”.

Subsec. (d)(1). Pub. L. 101–508, § 4006(a)(2)(A), substituted “90 days each, a subsequent period of 30 days, and a subsequent extension period during the individual’s lifetime” for “90 days each and one subsequent period of 30 days during the individual’s lifetime”.

1989—Subsec. (a). Pub. L. 101–234repealed Pub. L. 100–360, § 101(1), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment note below.

Subsecs. (b) to (d)(1), (2)(B), (e) to (g). Pub. L. 101–234repealed Pub. L. 100–360, § 101(2)–(6), and provided that the provisions of law amended or repealed by such section are restored or revived as if such section had not been enacted, see 1988 Amendment notes below.

1988—Subsec. (a). Pub. L. 100–360, § 101(1), struck out former pars. (1) to (4) and added new pars. (1) to (4) which read as follows:

“(1) inpatient hospital services;

“(2) extended care services for up to 150 days during any calendar year;

“(3) home health services; and

“(4) in lieu of certain other benefits, hospice care with respect to the individual during up to two periods of 90 days each, a subsequent period of 30 days, and a subsequent extension period with respect to which the individual makes an election under subsection (d)(1) of this section.”

1980—Subsec. (a)(3). Pub. L. 96–499, § 930(b), substituted “home health services” for “post-hospital home health services for up to 100 visits (during the one-year period described in section
1395x(n) of this title) after the beginning of one spell of illness and before the beginning of the next”.

Subsec. (d). Pub. L. 96–499, § 930(c), struck out subsec. (d) which authorized payment for post-hospital home health services furnished an individual only during the one year period described in section
1395x(n) of this title following his most recent hospital discharge which met the requirements of such section and only for the first 100 visits in such period.

1968—Subsec. (a). Pub. L. 90–248, § 143(b), inserted “or, in the case of payments referred to in section
1395f(d)(2) of this title to him” after “on his behalf” in text preceding par. (1).

Subsec. (a)(1). Pub. L. 90–248, § 137(a)(1), increased the maximum duration of benefits from 90 to 150 days minus 1 day for each day of inpatient hospital services in excess of 90 received during any preceding spell of illness (if such individual was entitled to have payment for such services made under this part unless he specifies that he does not desire to have such payment made).

Subsec. (b)(1). Pub. L. 90–248, § 137(a)(2), changed the limitation on payments from 90 to 150 days minus 1 day for each day of inpatient hospital services in excess of 90 received during any preceding spell of illness (if such individual was entitled to have payment for such services made under this part unless he specifies that he does not desire to have such payment made).

Subsec. (c). Pub. L. 90–248, § 138(a), increased the limit from 90 to 150 days so that if an individual was an inpatient of a psychiatric or tuberculosis hospital on the first day of the first month for which he is entitled to benefits, the days he was an inpatient in the 150-day period immediately before such first day are included in determining the limit under subsec. (b)(1) insofar as such limit applies to (1) inpatient psychiatric hospital services and inpatient tuberculosis hospital services, or (2) inpatient hospital services for an individual who is an inpatient primarily for the diagnosis or treatment of mental illness or tuberculosis (but are not included in determining such limit as it applies to other inpatient hospital services or in determining the 190-day limit under subsec. (b)(3)).

Pub. L. 90–248, § 146(a), provided that the limitation of allowable days of inpatient hospital services will not apply to services provided to an inpatient of a tuberculosis hospital.

Effective Date of 2003 Amendment

Pub. L. 108–173, title V, § 512(d),Dec. 8, 2003, 117 Stat. 2300, provided that: “The amendments made by this section [amending this section and sections
1395f and
1395x of this title] shall apply to services provided by a hospice program on or after January 1, 2005.”

Amendment by section 4201(c)(1) ofPub. L. 105–33applicable to services furnished on or after Oct. 1, 1997, see section 4201(d) ofPub. L. 105–33, set out as a note under section
1395f of this title.

Pub. L. 105–33, title IV, § 4449,Aug. 5, 1997, 111 Stat. 424, provided that: “Except as otherwise provided in this chapter [chapter 4 (§§ 4441–4449) of subtitle E of title IV of Pub. L. 105–33, amending this section and sections
1395f,
1395x, and
1395pp of this title and enacting provisions set out as notes under section
1395f and
1395x of this title], the amendments made by this chapter apply to benefits provided on or after the date of the enactment of this chapter [Aug. 5, 1997], regardless of whether or not an individual has made an election under section 1812(d) of the Social Security Act (42 U.S.C. 1395d(d)) before such date.”

Pub. L. 105–33, title IV, § 4611(f),Aug. 5, 1997, 111 Stat. 474, provided that: “The amendments made by this section [amending this section and sections
1395u,
1395x, and
1395ff of this title] apply to services furnished on or after January 1, 1998. For purpose of applying such amendments, any home health spell of illness that began, but not [sic] did not end, before such date shall be considered to have begun as of such date.”

Pub. L. 101–508, title IV, § 4006(c),Nov. 5, 1990, 104 Stat. 1388–43, provided that: “The amendments made by this section [amending this section and section
1395f of this title] shall apply with respect to care and services furnished on or after January 1, 1990.”

“(1) In general.—Except as provided in paragraph (2) and subsection (b), the amendments made by this subtitle [subtitle A (§§ 101–104) of title I of Pub. L. 100–360, amending this section and sections
1395c,
1395e,
1395f,
1395i–2,
1395k,
1395x,
1395cc, and
1395tt of this title] shall take effect on January 1, 1989, and shall apply—

“(A) to the inpatient hospital deductible for 1989 and succeeding years,

“(B) to care and services furnished on or after January 1, 1989,

“(C) to premiums for January 1989 and succeeding months, and

“(D) to blood or blood cells furnished on or after January 1, 1989.

“(2) Elimination of post-hospital requirement for extended care services.—The amendments made by this subtitle, insofar as they eliminate the requirement (under section 1812(a)(2) of the Social Security Act [42 U.S.C. 1395d(a)(2)]) that extended care services are only covered under title XVIII of such Act [42 U.S.C. 1395 et seq.] if they are post-hospital extended care services, shall only apply to extended care services furnished pursuant to an admission to a skilled nursing facility occurring on or after January 1, 1989.”

Effective Date of 1983 Amendment

Amendment by Pub. L. 97–448effective as if originally included as a part of this section as this section was amended by the Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97–248, see section 309(c)(2) ofPub. L. 97–448, set out as a note under section
426–1 of this title.

Effective Date of 1982 Amendment

Amendment by section 122(b) ofPub. L. 97–248applicable to hospice care provided on or after Nov. 1, 1983, see section 122(h)(1) ofPub. L. 97–248, as amended, set out as a note under section
1395c of this title.

Effective Date of 1981 Amendment

Pub. L. 97–35, title XXI, § 2121(i),Aug. 13, 1981, 95 Stat. 796, provided that: “The amendments made by this section [amending this section and sections
1320c–3,
1320c–4,
1320c–7,
1395f, and
1395x of this title] (other than by subsection (h) [repealing provisions set out as a note under section
1395ll of this title]) shall apply to services furnished in detoxification facilities for inpatient stays beginning on or after the tenth day after the date of the enactment of this Act [Aug. 13, 1981].”

Effective Date of 1980 Amendment

Amendment by section
930(b)–(d) of Pub. L. 96–499effective with respect to services furnished on or after July 1, 1981, see section 930(s)(1) ofPub. L. 96–499, set out as a note under section
1395x of this title.

Pub. L. 96–499, title IX, § 931(e),Dec. 5, 1980, 94 Stat. 2634, provided that: “The amendments made by subsections (a) through (d) of this section [amending this section and sections
1395f and
1395x of this title] shall become effective on April 1, 1981.”

Effective Date of 1968 Amendment

Pub. L. 90–248, title I, § 129(d),Jan. 2, 1968, 81 Stat. 849, provided that: “The amendments made by this section [amending this section and sections
426,
1395e,
1395f,
1395k,
1395l,
1395n,
1395x, and
1395cc of this title and section
228s–2 of Title
45, Railroads] shall apply with respect to services furnished after March 31, 1968, except that subsection (c)(5) of such section [amending section
1395f of this title] shall become effective with respect to services furnished after the date of enactment of this Act [Jan. 2, 1968].”

Pub. L. 90–248, title I, § 143(d),Jan. 2, 1968, 81 Stat. 858, provided that: “The provisions made by subsection (a) of this section [amending section
1395x of this title] shall become effective as of July 1, 1966, and the provisions made by subsections (b) and (c) of this section [amending this section and section
1395f of this title] shall apply to services furnished with respect to admissions occurring after December 31, 1967, and to outpatient hospital diagnostic services furnished after December 31, 1967, and before April 1, 1968.”

“(1) In general.—The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall establish a Medicare Hospice Concurrent Care demonstration program at participating hospice programs under which Medicare beneficiaries are furnished, during the same period, hospice care and any other items or services covered under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) from funds otherwise paid under such title to such hospice programs.

“(2) Duration.—The demonstration program under this section shall be conducted for a 3-year period.

“(3) Sites.—The Secretary shall select not more than 15 hospice programs at which the demonstration program under this section shall be conducted. Such hospice programs shall be located in urban and rural areas.

“(b) Independent Evaluation and Reports.—

“(1) Independent evaluation.—The Secretary shall provide for the conduct of an independent evaluation of the demonstration program under this section. Such independent evaluation shall determine whether the demonstration program has improved patient care, quality of life, and cost-effectiveness for Medicare beneficiaries participating in the demonstration program.

“(2) Reports.—The Secretary shall submit to Congress a report containing the results of the evaluation conducted under paragraph (1), together with such recommendations as the Secretary determines appropriate.

“(c) Budget Neutrality.—With respect to the 3-year period of the demonstration program under this section, the Secretary shall ensure that the aggregate expenditures under title XVIII [42 U.S.C. 1395 et seq.] for such period shall not exceed the aggregate expenditures that would have been expended under such title if the demonstration program under this section had not been implemented.”

Protecting Home Health Benefits

Pub. L. 111–148, title III, § 3143,Mar. 23, 2010, 124 Stat. 442, provided that: “Nothing in the provisions of, or amendments made by, this Act [see Short Title note set out under section
18001 of this title] shall result in the reduction of guaranteed home health benefits under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.].”

“(a) In General.—The Secretary [of Health and Human Services] shall conduct a demonstration project for the delivery of hospice care to medicare beneficiaries in rural areas. Under the project medicare beneficiaries who are unable to receive hospice care in the facility for lack of an appropriate caregiver are provided such care in a facility of 20 or fewer beds which offers, within its walls, the full range of services provided by hospice programs under section 1861(dd) of the Social Security Act (42 U.S.C. 1395x(dd)).

“(b) Scope of Project.—The Secretary shall conduct the project under this section with respect to no more than 3 hospice programs over a period of not longer than 5 years each.

“(c) Compliance With Conditions.—Under the demonstration project—

“(1) the hospice program shall comply with otherwise applicable requirements, except that it shall not be required to offer services outside of the home or to meet the requirements of section 1861(dd)(2)(A)(iii) of the Social Security Act [42 U.S.C. 1395x(dd)(2)(A)(iii)]; and

“(2) payments for hospice care shall be made at the rates otherwise applicable to such care under title XVIII of such Act [42 U.S.C. 1395 et seq.].

The Secretary may require the program to comply with such additional quality assurance standards for its provision of services in its facility as the Secretary deems appropriate.

“(d) Report.—Upon completion of the project, the Secretary shall submit a report to Congress on the project and shall include in the report recommendations regarding extension of such project to hospice programs serving rural areas.”

OIG Report on Notices Relating to Use of Hospital Lifetime Reserve Days

Pub. L. 108–173, title IX, § 953(d),Dec. 8, 2003, 117 Stat. 2428, provided that: “Not later than 1 year after the date of the enactment of this Act [Dec. 8, 2003], the Inspector General of the Department of Health and Human Services shall submit a report to Congress on—

“(1) the extent to which hospitals provide notice to medicare beneficiaries in accordance with applicable requirements before they use the 60 lifetime reserve days described in section 1812(a)(1) of the Social Security Act (42 U.S.C. 1395d(a)(1)); and

“(2) the appropriateness and feasibility of hospitals providing a notice to such beneficiaries before they completely exhaust such lifetime reserve days.”

“(a) In General.—The Medicare Payment Advisory Commission shall conduct a study to examine the factors affecting the use of hospice benefits under the medicare program under title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], including a delay in the time (relative to death) of entry into a hospice program, and differences in such use between urban and rural hospice programs and based upon the presenting condition of the patient.

“(b) Report.—Not later than 18 months after the date of the enactment of this Act [Dec. 21, 2000], the Commission shall submit to Congress a report on the study conducted under subsection (a), together with any recommendations for legislation that the Commission deems appropriate.”

“(1) In general.—Notwithstanding any provision of title XVIII of the Social Security Act [42 U.S.C. 1395 et seq.], the Secretary of Health and Human Services shall establish a transition for the aggregate amount of expenditures that are transferred from part A, to part B, of title XVIII of the Social Security Act [42 U.S.C. 1395c et seq., 1395j et seq.], as a result of the amendments made by this section [amending this section and sections
1395u,
1395x, and
1395ff of this title], during each of the years during the period beginning with 1998 and ending with 2002 according to this subsection. Under the transition for each such year, the Secretary shall effect such transfer, between the trust funds under such parts, as will result in only the proportion (specified in paragraph (2)) of such aggregate expenditures for the year being transferred from such part A to such part B.

“(3) Application in establishing monthly premiums for 1998 through 2003.—

“(A) In general.—For purposes only of computing the monthly premium under section 1839 of the Social Security Act (42 U.S.C. 1395r), the monthly actuarial rate for enrollees age 65 and over shall be computed as though any reference in paragraph (1) of this subsection to 2002 were a reference to 2003 and as if the following proportions were substituted for the proportions specified in paragraph (2):

“(i) For 1998, 1/7.

“(ii) For 1999, 2/7.

“(iii) For 2000, 3/7.

“(iv) For 2001, 4/7.

“(v) For 2002, 5/7.

“(vi) For 2003, 6/7.

“(B) No impact on government contribution.—Subparagraph (A) does not apply in determining the amount of the Government contribution under section 1844 of the Social Security Act (42 U.S.C. 1395w).”

Repeal of 1988 Expansion of Medicare Part A Benefits

For provisions repealing amendment by section 101 ofPub. L. 100–360, restoring or reviving this section as if section 101 ofPub. L. 100–360had not been enacted, and providing a transition period for medicare beneficiaries with respect to inpatient hospital services and extended care services provided on or after Jan. 1, 1990, and providing an exception to such restoration for certain hospice care, see section
101(a)–(b)(2) of Pub. L. 101–234, set out as a note under section
1395e of this title.